The concept of hysteria as mirror of the relation between clinical and cultural psychology

Why Hysteria Must Be Feminine

The question of diagnosing hysteria, which was almost exclusively limited to women, can be fundamentally assigned to three different characteristic causes: 1. the physiological, or biopsychological, distinction between the sexes, 2. the patriarchal oppression of women by men, and 3. the creation of the generally accepted world view by men. As will be shown, all three aspects play a central role in the underlying thematic question of the development of hysteria.

The Hysterical Distinction Between the Sexes

Until the advanced 19th century, it was still believed that the disease was only a female phenomenon because a “psycho-organic difference of the sexes […] [plays] the important role [for becoming hysteric]” (von Feuchtesleben, 1845, p. 244) and led to the fact that such a disease could only be found in women. Also in the following century, people focused on the physiological distinction with regard to diagnosis. Freud states in 1905 that the cause of the development of hysteria with “[…] general and exceptional validity […]” (Fragments of an Analysis of Hysteria, p. 6) is to be found in the suppressed sexual drives, which are articulated much more strongly in women. In the cultural context prevailing at that time, but also that of the following decades, mental phenomena were often explained by psychosexual differences of women and men (Bohan, 1992). Occasionally, even until the end of the 20th century, the archaic opinion was held that the personality difference of the sexes was indispensable and that a gendered hysterical core, was predominant in women (King, 2001). Today we know that from a biopsychological perspective on thinking, acting, and feeling, the sexes differ much less than originally thought. Pinel & Pauli (2015) refute the dichotomous view of sexuality based on several medical findings, which they summarize in their introduction to biopsychology. Sexual dimorphisms in cortical structures of the brain, are found only in extremely weak expression and only in various small nuclei of the hypothalamus (Pinel & Pauli, 2015). Furthermore, sex hormones, which influence behavior in a sex-specific manner, cannot be as clearly delineated as long assumed. Aromatization is the name given to a biochemical process in which hormones are converted to other hormones by various enzymes. In some cells of the brain and gonads, estradiols, which were originally feminizing, have a masculinizing effect on the developmental process of a boy in this way. Several studies have found that the supposedly purely female sex hormone estrogen, provides the impetus for the development of the masculinization of a brain (Pinel & Pauli, 2015, p. 380). The “man-is-man and woman-is-woman implication that testosterone conditions masculinity and estrogens condition femininity is false” (Pinel & Pauli, 2015, p. 386). This suggests that a personality difference between the sexes, which in turn leads to differences in the expression of mental illness, is not necessarily due to physical or hormonal differences. As early as the 1960s, some leading scientists and psychiatrists began to point to the social role of women in society as a major factor in many mental health problems. “Woman is nurturance.” wrote Joseph Rheingold (1964, p. 54), meaning that the perception and experience of a woman is more of an inclination or disposition than an indispensable psychophysiological condition of her own sex. Rheingold (1964) thus aptly describes how strongly the gender identification of an individual depends on his social environment, and, according to the approach of the well-known sociologist and psychologist Herbert Mead (1968), only defines himself as a person through this environment. In conclusion, it can be said that there has happened a shift in the cultural psychological meaning-making of psychiatric deseases here: the anatomical-medical difference of the sexes has been further and further delimited from the development of mental illness symptoms. Hence, social workers, psychiatrists and psychologists increasingly focused on the social circumstances of those affected. This contributed to a change in the gender-specific classification of hysteria and the categorical classification of hysteria and woman, which characterized the phenomenon from its historical emergence, became obsolete. Finally, it can also be summarized that the physiological causes of mermals were decisive for the feminization of the clinical picture, but the approach of diagnostics gradually moved away from this idea of an etiology of hysteria.

The Hysterical Patriarchal Oppression of Women

But how is the cultural psychological meaning-making of psychopatholocial categories constructed? Another important factor contributing was undoubtedly the fact that a male-dominated society reduced women to physical characteristics and domestic abilities. Alfred Adler, who was far ahead of his time with his thoughts in emancipatory form, wrote as early as 1927 in his bestseller Menschenkenntnis:

“As things stand up to now, there is a continual striving for superiority over woman on the part of man and, correspondingly, a constant dissatisfaction with male privileges on the part of woman. Given the close affinity of the two sexes, it is understandable that such a tension, a constant shaking of their psychic harmony, leads to far-reaching disturbances, from which results a psyche that […] must be felt as extraordinarily agonizing.” (S. 308).

The power-structural reduction predestined women to show formerly hysterical symptoms such as paralysis, somatoform disorders and multiple personality disorders. By way of introduction, a quote from Rutschky (1997) should also be given as an example, which problematizes the sociocultural starting point of the topic. Rutschky writes: “[the] patriarchal social order [challenged] female desire or even desire for education, science, and suffrage” (1997, p. 3). King (2001), for example, is also of the opinion that already during the pubertal development of young women, too little room for development has been made available in social and psychological terms, which “[…] made certain integration processes more difficult.” (p. 239). Especially in adolescence, which is defined in developmental psychology as a time of emotional and social development, regression of the person can lead to serious personality problems. Here, hysteria becomes a reaction to this regression and an expression of protest (see King, 2001). Hysterical symptoms thus became, especially in the female gender, a “manifestation of defense mechanisms against oppression, […] a form of articulation and [an attempt to] assert one’s own interests as an expression of ambivalent protest.” (King, 2001, p. 241). Also Foucault (1976) writes in his widely cited work The Will to Know—Sexuality and Truth I how strongly the sexual expression, the fantasies of women were suppressed and dictated in all areas of society. As could be seen, various processes of integration into society were made impossible for women and they were often given too little room for development while maturing into a fully recognized member of society. As a result, many women were not able to enter a phase of self-discovery and self-assertion, or only an inadequate one, which led to psychological problems in particular (Foucault, 1976).

The consequences of the different social role, on which in the further course of the work (cf. para. 3.2 ff.) still a focus will lie, contributed significantly to the fact that diagnosis of hysteria could be made primarily in women. In the conclusion of the time, this contributed to the fact that this mental illness, was unconditionally gender-specified in its meaning-making.

The Hysterical Creation of the Generally World View

The emergence of the general worldview, comes as another factor centrally to bear, if one faces the question of the categorical gender-specific assignment of hysteria. The meanwhile generally recognized psychological phenomenon of the self-fulfilling prophecy is decisive here. It may be no coincidence that the first theories on this subject emerged in the course of the second half of the 20th century, which was so relevant to the research question. The self-fulfilling prophecy states that the probability of the occurrence of an event increases radically with increasing expectation of this particular event (Merton, 1948). In a study from 1968, which was to prove decisive for the development of social psychology in the following years, Rosenthal and Jacobson (1968) found that an expectation of comparatively high performance of individual students led to the fact that these very students developed as more gifted and distinguished themselves by special achievements. Rosenthal and Jacobson (1968) were thus able to confirm their hypothesis, according to which an attitude of expectation causally correlates with the probability of occurrence of the expected event—also known as the Pygamlion-Effect, named according to the greak myth of Pygmalion by Vergil (approx. 40 v.Chr.) where a sculpurer falls ins love with its sculpture and wishes that it could become a real person so much, that it acutally turnes into flesh and bones 1 day. Yet, the results of the study by Rosenthal and Jacobson (1968) clearly point to the influence of social factors regarding the cultural psychological meaning-making of behavioral patterns. Bohan (1992) aptly points this out as indispensable in relation to statements concerning hysteria and women. “The concreteness of changed conditions produced by expectation is a fact, a reality. […] it is extremely important when assessing the validity of psychological studies [and assumptions] on woman.” (S. 68). Medical practice was and is dominated by the male gender, which consequently contributes to a male-dominated expectation of diagnosis of illnesses. The effect of self-fulfilling prophecy, respectively the Pygmalion-Effect could be articulated especially regarding mental illnesses. This is also the case with hysteria (Rutschky, 1997). One proof of this is that already in 1917 and 1918 individual veterans returned from the First World War with hysterical symptoms, but they were given a different diagnosis, because it was considered impossible that men could show hysterical symptoms. This phenomenon was then simply renamed neurastia in men (Konrad et al., 2000). Thus, it can be clearly stated that psychiatric and psychological diagnosis and definitions disadvantaged women and were systematically assigned to one gender (Dodd, 2015). Finally, it must also be added that it was primarily women who sought therapeutic treatment. Thus, hysterical symptoms could be detected less in men from the outset (Zaretsky, 2004).

In conclusion, due to the arguments put forward, no one can be surprised why the diagnosis of hysteria was almost exclusively limited to women and femininity was associated with the hysterical symptomatology of infantility, pretense, emotional instability.

Hysterical Politics

At the beginning it can be pointed out that the development of the concept of hysteria was constitutively influenced by the political changes that took place within the last century. To gain an understanding of the conceptual restructuring of the clinical picture, it is therefore indispensable to subject the political context to special consideration. A look at the socio-political fruits of the Enlightenment allows us to draw conclusions about the development of hysteria. During the 19th century in Europe, for example, secularization solidified with increasing speed. Religion played more and more a rather subordinate role (Blumenberg, 1974). Yet, the church stood (and to some extent still stands) for patriarchal, heterosexual structures and was used for a long time to politically justify a strict demarcation within power structures of gender in relation to sexual desires. Cynically, Gourin (2016) speaks of an economy of desire when he writes about how the church uses sexual desire in order to control the mass. An awareness of this, emerged especially during the 68 civil rights movement and articulated itself on a psychological level through, for example, ideological contributions from psychoanalysis. The further developments of Sigmund Freud’s theories, namely Wilhelm Reich’s Freudomarxism (1929) and Anna Freud’s Ego Psychology (1936), were taken up in this context and the exercise of social control by political systems (and the church) received increasing attention (Sager, 2015). So did Wilhelm Reich (1933) wrote that it is the hierarchical claims to power from which hysteria springs and that neurosis arises because of repressed and pent-up sexual energy, generated by repressive mechanisms stemming from the authoritarian family and marital structure. Based on the theories emanating from Freud to problematize the repression of sex, a confrontation with it becomes more and more central to society. Foucault (1977) writes in The Will to Know, “[…] thus the seeds of resistance scatter across social stratifications and individual units.” (p. 97). Psychoanalytic publications were much easier for the layperson to read, since some of them were based more on everyday life, and others were written in a less lexically-semantically technical way. It is also interesting to note that those same writings, particularly attracted a female audience and were widely read by them, which of course gave immense impetus to female engagement with the subject matter. Freud pleaded early on for women to be admitted to the psychoanalytic association (Gerisch, 2006). Moreover, during and after World War II, the number of practicing psychologists and therapists grew almost exponentially. “Psychological expertise [helped] new practices of self-reflection [and] thus strengthened […] against the old forms of control by community” (Zaretsky, 2004, p. 399 ff.). The dependence of social concepts, such as gender relations and sexuality are questioned. Titels of books, such as The Female Delusion or Women’s Self-Liberation: A Concept of Emancipation emerge as a result (Zaretsky, 2004). Furthermore, for the political influences on the development of hysteria, the women’s movements, and the gay rights movements in the wake of the aforementioned 68 civil rights movement are also of fundamental importance. In this regard, Foucault (1967) noted that “homosexuality [in the course of the 19th century] began to speak of itself, to insist on its legitimacy or its naturalness” (p. 101). Particularly mental clinical pictures, as an expression of social values, were sharply criticized in this course. Staub (2011) writes retrospectively on this:

“The invocation of sociological explanation for mental illness plays a significant role in the counter-culture of the 1960s. In the 1970s and 1980s, political activists from the gay rights movement and the women movement began targeting the APA using similar frameworks.” (p. 321).

The fact that the distribution of roles and gender relations support the diagnostic development of the concept of hysteria was pointed out at the beginning of the paper. Furthermore, it could be shown how dependent this cultural psychological development is, especially on the political developments of society and how strongly it influences them vice versa.

The Less Hysterical Gender Relations

It has already been implicitly stated how the representation and conception of gender continued to change, which allowed the comprehensive transformation of the concept of hysteria to emerge. This upheaval penetrates to family structures and influences upbringing, family principles, and value judgments. In Bohan's (1992) view, “[will] One consider oneself male or female depending simply on one was defined and raised as male or female” (p. 71). Her phrase represents the determinant nature of these familial structures. The change in private space and the definition of privacy opens the possibility for men, but especially for women, of a rethinking of the concept of family and home (Zaretsky, 2004, p. 405). The “image of masculinity is also changing.” (Zaretsky, 2004, p. 405 ff.) in this context. The social change leads to the emergence of specific power dispositives, which express themselves especially in the family context of the distribution of tasks. Examples of this are the management of children’s lives, their moral upbringing, household responsibilities and income. The woman and the female body are no longer defined only as a medium of reproduction but emancipate themselves from its strict categorization. The connection between emancipatory development and histrionic neurosis first finds an inventory in Riemann (1975). In his work “Basic Forms of Anxiety” (1975), he refers with regard to the development of hysteria to the social upheavals within the Western society of the 20th century and postulates a cause of the development of hysteria in the unequal distribution of roles between the sexes and the accompanying emergence of fears, desires and compensation mechanisms of the affected persons. He also takes the position that this unequal distribution of roles, has led to a gender-specific assignment, early imposed conventions and consequently, especially in female development, there was a special development potential for histrionic neuroses (Riemann, 1975). In a similar context and taking this idea further, Rutschky (1997) specifically points to the fact that it had long been very difficult for women to assert their own areas of interest. Especially in traditional bourgeois circles of the society of Western countries, the conventions of gender specificity were immense. Furthermore, and much more recently, King (2001) has devoted extensive attention to the psychological perspective on the development of hysteria. Unlike Riemann (1975) and Rutschky (1997), King (2001) outlines in one of her essays the thesis, the developmental psychological consequences of patriarchalism on so-called hysterical behavior patterns. She conceptualizes hysterical symptoms in women as the articulation of an outcry against the conventions imposed on her. Referring to the emancipatory developments of the past decades, King (2001) writes that over time women “adapt[ed] to their ego development and thus liberate[d] themselves to some extent from their] ‘childlike dependence’” (p. 245). Formerly, hysteria was conditioned by the definition of the “[…] nervous wife, frigid wife, hysterical daughter [or the] precocious child” (Faucault, 1967, p. 109). In particular, young women became less and less inhibited in their developmental desires as the 20th and 21st centuries progressed. Paradigmatic gender relations with a strongly subordinated role of women have tended to dissolve in Central Europe, especially in the past decades, whereby new development potentials on both sides of the sexes, but especially with regard to behavior-determining conditions for women, could emerge. The emancipation of women, as well as that of men, has led to the fact that only rarely are women systematically hindered in their educational and developmental aspirations as was the case in the past. Today, in comparison to the last century, in many areas of community life, a balance has been emerged to some extent. Despite the patriarchal structures that still exist in many areas, the inhibited life and development opportunities of young women in Germany today are somewhat a thing of the past, King (2001) sums up at the turn of the millennium.

The Hysterical Conceptualizations of Psychopathology

Mental clinical allegories, as an expression of social values and norms, respectively the cultural psychological meaning-making, show the conceptualization of the psychological phenomena, such as the one of hysteria. The abolition of this classification is obvious, considering the circumstances presented in the previous chapters. First, the etymology of the word of uterus was increasingly considered inappropriate (Mentzos, 2012). Also, due to the changes in social and family structures outlined above, the neurotic character of the phenomenon experienced fewer opportunities for development. This caused a regression and shift of the underlying symptomatology (Riemann, 1986). The term was hysteria long characterized by a psychoanalytic conception and included many symptomatologies which were “[…] all lumped together […]” as King 2000, (p. 237) states. It became too woolly and overstylized as an attributional term (Mentzos, 2006). During the 20th century, the sexual dispositive of hysteria is no longer merely psychologized and medicalized (Faucault, p. 109). Due to the cultural psychological conditioned development of the meaning of the term, hysteria became more and more negatively connoted (Mentzos, 2006). Increasingly, personality traits, such as infantility or emotionality, were associated with it in non-neurotic people (King, p. 237). The fact that the psychopathological definition of the former word hysteria has become obsolete or has split into terms such as conversion disorder or somatization disorder, is thus quite easy to understand in the context of the two preceding paragraphs. The classification of mental illnesses is subject to constant change. A changed that is tied to the dynamics of meaning-making processes within society.